One question we are asked consistently by people inquiring about our services is “Does Medicare Insurance pay for custodial (private duty) home care services”? Custodial in-home care is also referred to as “private duty” home care.

Custodial Care or Private Duty Home Care is non-medical care that helps individuals with his or her activities of daily living, preparation of special diets and self-administration of medication not requiring constant attention of medical personnel. Providers of custodial care are not required to undergo medical training. Therefore, ‘custodial care’ or ‘private duty’ home care, the care that provides the ‘activities of daily living’ and enables seniors to ‘age-in-place’ (usually their home) is often referred to as “non-medical” care.

It occurred to me that I have not created a blog post focused on the role of Medicare as it pertains to private-duty home care for seniors. So, with a few necessary definitions provided along the way, here goes.

First, let’s understand that Medicare insurance is a complex subject. Medicare was established by the federal government because at the time, most private insurers would not sell health insurance policies to older adults. From Wikipedia, “Medicare is a national social insurance program, administered by the U.S. federal government since 1965, currently using about 30 private insurance companies across the United States. Medicare was established by the federal government to care for a very vulnerable part of our population. However, private insurance companies execute the health insurance program.

Medicare guarantees access to health insurance for Americans aged 65 and older who have worked and paid into the system, and younger people with disabilities as well as people with end stage renal disease (Medicare.gov, 2012) and persons with amyotrophic lateral sclerosis. As a social insurance program, Medicare spreads the financial risk associated with illness across society, even to people who cannot use it and may never want it or use it, and thus has a somewhat different social role from private insurance, which involves a risk portfolio (underwriting) and adjusts premiums according to perceived risk.”

Today Medicare covers more than 50 million people, including most people 65 and older and approximately 8 million younger adults with disabilities. Medicare is not free, nor does it cover everything! Medicare is similar to group insurance or individual health insurance in that it generally pays for acute care and skilled care, not custodial care with two notable exceptions.

The notable exceptions are two limited and very specific conditions:

Medicare Part A pays for custodial care when it is part of hospice care, and

Medicare pays for custodial care in care settings such as home health care, but only if the beneficiary also receives skilled services and meets other criteria such as having a physician’s order for the services and using services provided only by Medicare-approved agencies. Medicare stops paying for custodial care when the patient no longer needs skilled care.

For clarity the following definitions are also important.

Acute Care is a pattern of health care in which a patient is treated for a brief but severe episode of illness, for the sequel of an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personnel using complex and sophisticated technical equipment and materials, and it may involve intensive or emergency care. This pattern of care is often necessary for only a short time, unlike chronic care.

Skilled Care is a type of intermediate care in which the patient or resident needs more assistance than usual, generally from licensed nursing personnel and certified nursing assistants.

So with the above listed limited exceptions, Medicare DOES NOT pay for custodial (private duty) in-home care unless the senior first needs skilled (medical) care.

What Does Medicare Cover Relative to In-Home Care?

Medicare Part A covers home health care services that include skilled nursing care, physical therapy, occupational therapy, speech therapy, and certain other health care services that patients receive in their homes for the treatment of or recovery from an illness or injury. In these cases, cases associated with these types of skilled care needs, Medicare covers non-medical or custodial (private duty) care needs. Medicare stops paying for custodial care when the patient no longer needs skilled care. Further, Medicare does not pay for long-term stays in nursing homes.

So that’s as clear as I can state the facts regarding Medicare and what it covers relative to private duty home care. I hope it helps. Should you have other questions regarding Medicare and private duty home care, feel free to contact me at kjohnson@visitingangels.com.